Acute Intoxication is a Mental Disorder

The longer I work on policing and mental health, the less frequently I experience certain things which used to hit me square in the face every time I went near the topic as a PC: a new piece of knowledge that leaves you entirely confused and thoroughly re-examining the paradigm you’re trying to get your head around. Having done a fair few talks over the years to professionals in policing and in mental health, I thought I had it fairly squared away in my head how to answer the questions that arise when discussing intoxication by drugs or alcohol, relative to police decisions about things like section 136 of the Mental Health Act. And then, Wiltshire Police rang for an opinion on a psychiatric report they’d received ahead of an inquest. I’m still thinking this through, several weeks later, because it’s almost entirely beyond comprehension this hasn’t come up before.

In February 2017, the police were called to an incident in Salisbury where they found a very drunk individual who had involuntarily expelled urine and could seemingly not stand or talk. Officers spent considerable time with him, calling an ambulance and whilst the paramedics did undertake some level of assessment, no records exist to show exactly what that entailed. Having made a decision the man did not require conveyance to or treatment in an Emergency Department, they left decisions about his safeguarding to the police. For reasons I’m still unclear about, the officers left him in situ on a winter’s evening and he died of acute alcohol intoxication and hypothermia. The Coroner’s verdict ruled this was an accidental death contributed to by the neglect of both paramedics and police officers. You might be wondering on the basis of that summary what this has to do with mental health?

The Coroner in this case commissioned an independent psychiatric opinion, seeking answers to certain questions. The pertinent ones for this post are –

At the time of police and paramedics contact, was this man suffering from a mental disorder?

If so, could section 136 of the Mental Health Act have been used.

And if so, should s136 MHA have been used?!

I’ll let you have the punchline before making the points I want to make: the answer to all three questions was ‘Yes’ – he was mentally disordered (acute alcohol intoxication); ‘Yes’, section 136 can be applied to any mental disorder that is not a disorder related to dependence upon alcohol (abuse / misuse being different to dependence and addiction); and ‘Yes’, in preference to leaving the man in a public toilet, the officers should have used section 136 to safeguard him, notwithstanding the paramedics’ opinion.

WHERE DO I START?!

I decided I would write a post on this inquest when I had time, but I’ve been motivated to make the time, based upon a conversation on social media only this morning: the AMHP forum on Facebook are currently discussing whether there has been a real and steep rise in the use of s136 MHA since the legal changes last December. Several contributors to that discussion are lamenting perceived over-use of the power by police officers when people are ‘not mentally ill, they are just drunk and disorderly’. Haven’t we always been told that drunkenness is not a mental illness and that the Mental Health Act can’t be used on someone who is intoxicated?

I have spent fifteen years doing policy related work and I will be honest: I’ve had psychiatrists, mental health nurses and others shout at me(!) when discussing issues around s136 and Places of Safety because of their no-doubt genuine belief that drunkenness should be dealt with in a different way. I’ve heard argument that where s136 is used on drunk people where there is no known background of mental health problems and no context on first contact that showed any evidence of self-harm or suicide, that most people are assessed as having no extant medical needs. They might need a bacon sandwich and a cup of tea to sort their hangover, but no referral to a GP or community mental health team.

And let’s not forget this: the much-lauded concept of street triage started in the Cleveland Police are in 2012 and that began after frustration in mental health services that their local officers were using s136 too frequently on drunk people who had no ongoing care needs at all once they’d sobered up. Having approached local senior officers to offer training, they found themselves rebuffed and street triage, to quote an AMHP from Middlesbrough, “is all about stopping the police from getting it wrong.” They found that over 95% of drunk people just sobered up and went home; the other 5% were those drunk people known to have a background of serious mental illness or who were found hurting themselves or in a precariously suicidal position. So, we’re now spending millions of pounds of public money on triage schemes which, amongst other things, aims to stop an over-medicalised response to the social issue of alcohol abuse.

NATIONAL POLICY

For all of these reasons, national guidelines in policing advise officers away from using s136 on drunk people unless there is that known background or context, because it plays the percentages in a realistic way if people are either conveyed to A&E for potentially toxic levels of alcohol consumption and, if people need legally detaining, arresting someone for being drunk in a public place or drunk and incapable does not preclude a MHA assessment for anyone who sobers up and who is still thought to be exhibiting unusual behavioural signs that may mean an underlying disorder. Remember the story of the bloke in Walsall who bought over-the-counter products to help him stop smoking and then drank a load of red wine? – he ended up sectioned under the MHA in hospital because after sobering up, there was a lingering effect of the alcohol and the medication that took three days to wear off.

But, it turns out it really is true that acute intoxication (by either drugs or by alcohol) is listed in the International Classification of Disease, 10th edition, published by the World Health Organisation as a mental disorder. The MHA can be applied to any mental disorder that is not a disorder related to dependence; therefore s136 is ‘in play’ for drunk people or those experiencing a drug-induced psychosis. I should imagine any mental health professionals reading this are starting to panic at the potential their local police officers may start scooping up nighttime economy punters and pouring them in to Places of Safety and Emergency Departments! …

Well, in his oral evidence to the Coroner’s Court, the expert psychiatrist did say that he was not arguing the police should be detaining all very drunk people under s136. What I left the Courtroom without, however, was a clear understanding from him of how a police officer could or should tell the difference between the very drunk person who should be detained under s136, from the very drunk person who should not. Maybe that detail will follow later. But what did become clear is that the reason for suggesting the use of s136 was merely as an alternative to leaving someone where they were. In reality, of course, those were not the only two options available – the officers could have removed the person to A&E under the Mental Capacity Act, they could have arrested for at least two criminal offences and in other incidents involving very drunk people there may be other offences committed or friends / family on hand to help that person without the police needing to act.

DECISIONS, DECISIONS

My final point is to ask what standard we are holding the police to in these matters? Having seen a copy of the psychiatrist’s report, I rang a few mental health professionals. “Did you know that acute intoxication (drugs or alcohol) is a mental disorder in ICD-10?” I also asked this on Twitter: literally no-one knew! I must have canvassed over a century’s worth of experience and none of them knew this. When that was explored in the Coroner’s Court, the psychiatrist also admitted that he’d shown his expert report to a Professor of Psychiatry who had apparently exclaimed, “Ooooh, I didn’t know that!” The expert went on, after that admission, to say he thought the fact Wiltshire Police officers didn’t know this as a ‘serious concern’.

I’m just going to say that one more time: two frontline police officers not knowing something was a mental disorder when a Professor of Psychiatry and a raft of mental health professionals with over a century of experience between them also did not know this is, apparently, a ‘serious concern’ … seriously?! What standard are we holding the police to here?! It is – quite frankly – completely ridiculous!

But let’s imagine these officers did know something that a whole mental health system (almost) full of professionals with postgraduate degrees appears to not know: how does that change any real-world decision-making?! What do we think a place of safety nurse or AMHP may say when we ring them up and explain, “We’ve detained this guy whose name we don’t yet know: he was lying drunk in a puddle of his own urine, unable to walk or talk and there was no background known or context of self-harm or suicide and we’ve brought him in under s136.” One professional admitted, perhaps because they know me well they felt they could speak freely, that they’d probably just say, “Michael, you’re taking the p*ss mate, you can f*ck off with that!” Seems fair enough, to me.

MEANWHILE IN THE REAL WORLD

I just can’t my head around any of this – it’s simply too weird for words. But if you are a police reader, you can have some fun with this: next time someone mentions the police should not be using s136 MHA on drunk people just say, “The ICD-10 lists acute intoxication as a mental disorder and as abuse of alcohol is not the same thing as dependence, the MHA can apply to it.” And then just watch their face – you’re welcome.

My opinion remains the same: we should stay well clear of s136 with drunk people unless we know from their background or the context we’re responding to that we need to have concerns about their mental health. This means (amongst other things) where someone is known to mental health services, currently or recently; where parties connected to the incident are telling you they have a history of mental health problems or where you find them hurting themselves or in suicidal state. Otherwise, safeguard that person in a different way that does not involve leaving them in a public place to freeze overnight.

Choose from letting family or friends help them; let another agency help them, if willing; use the MCA to remove them to A&E, or you could even arrest them for being drunk and incapable in a public place – just don’t leave them where you found them face down in a puddle of their own waste in the middle of winter. It’s a real shame that needs saying, isn’t it? – whether that’s to the police or to paramedics.

Winner of the President’s Medal from
the Royal College of Psychiatrists.